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Coma Exam

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421. CRACKCast E010 – Pediatric Resuscitation

normal at the time of ED presentation (50% of the time) but any non-hospital person who witnessed choking or cyanosis should be taken seriously ED evaluation depends on hx and physical exam investigations +/-: CBC, glucose, lytes, urine/blood cultures tox screen, ECG +-CT, CXR, children < 60 days should undergo thorough screening for infection with//without pediatrics assessment EMRAP Claudius and Keens suggests kids <1 month be admitted outcome: variable depending on etiology one retrospective (...) avoid the insult that caused asphyxia or ischemia gates around swimming pools, seat belts recognize and treat shock early 2) no flow untreated cardiac arrest: recognize ASAP 3) low flow (aka CPR phase) do CPR 4) post-resuscitation: complex number of factors involved post arrest brain injury coma, seizures, myoclonus, spectrum: full function–> brain death probably best to keep temp <36 degrees (based on adult studies in post VF arrests) and prevent fever post arrest myocardial dysfunction consider

2016 CandiEM

422. CRACKCast E009 – Adult Resuscitation

pneumothorax treat anaphylaxis control the airway Brain arrest / Cognitive arrest You show up to a code or patient is wheeled in who is comatose, but breathing and a pulse… (more in Episode 17 – Coma) Bottom line you think of something affecting both hemispheres using an approach like DIMS: Drugs Infection Metabolic Structural Approach this similarly to the post-ROSC patient and you won’t miss much. 3) Describe your approach to the post-cardiac arrest patient One great approach to the post arrest patient (...) is from Dr. David Sweet (Emergency Physician/ Intensivist at Vancouver General Hospital) His memory aid for the post arrest patient is: 1:2:2:3 1: one full set of vitals including glucose 2: two machines that you should call for ASAP – ECG and CXR 2: two bloods: full cardiac labs (CBC, troponin, lytes etc.) and an ABG 3: three basics: take a history, do a physical exam, and look at the old charts 4) Sleuthing out why the patient arrested: an approach to the history and physical History family

2016 CandiEM

424. Contrast-induced Nephropathy

or 0.5 mg/dL within 3 days of intravascular administration of contrast media in the absence of an alternative etiology. 1 This definition of CIN is the one most commonly used in the past in studies examining the risk, prevention, and treatment of CIN. More recent definitions of acute kidney injury have not yet been used extensively in the CIN literature. The precise mechanism of CIN is not entirely understood. The leading theories are that CIN results from hypoxic injury of the renal tubules induced (...) ). The pooled risk ratio was 0.69 (95% CI, 0.58 to 0.84) for N-acetylcysteine when LOCM was used, suggesting a clinically important benefit, and 1.12 (95% CI, 0.74 to 1.69) for N-acetylcysteine when IOCM was used. When we examined how the risk ratio estimates varied according to baseline characteristics of the study population, we did not observe any meaningful difference by age, baseline renal function, presence or absence of diabetes mellitus, or proportion of female patients. When we examined how results

2016 Effective Health Care Program (AHRQ)

425. Perinatal substance use: maternal

. They are analgesic and can induce euphoria and in high doses– stupor, coma and respiratory depression. Whereas, opioids include alkaloids derived from the opium poppy as well as synthetic drugs interacting with the same receptors in the brain and include oxycodone, heroin and methadone. They are analgesic and produce euphoria. 12 1.3.1 Pregnancy, fetal and neonatal exposure Table 3. Opioid/opiate exposure potential outcomes–pregnancy, fetal and neonatal Aspect Potential outcomes Pregnancy 13-15 • Stillbirth

2016 Queensland Health

426. Thermal resilience may shape population abundance of two sympatric congeneric Cotesia species (Hymenoptera: Braconidae). (Full text)

congeneric parasitoid species Cotesia sesamiae Cameron and Cotesia flavipes Cameron (Hymenoptera: Braconidae), we examined basal thermal tolerance to understand potential impact of climate variability on their survival and limits to activity. We measured upper- and lower -lethal temperatures (ULTs and LLTs), critical thermal limits [CTLs] (CTmin and CTmax), supercooling points (SCPs), chill-coma recovery time (CCRT) and heat knock-down time (HKDT) of adults. Results showed LLTs ranging -5 to 5°C and -15 (...) to -1°C whilst ULTs ranged 35 to 42°C and 37 to 44°C for C. sesamiae and C. flavipes respectively. Cotesia flavipes had significantly higher heat tolerance (measured as CTmax), as well as cold tolerance (measured as CTmin) relative to C. sesamiae (P<0.0001). While SCPs did not vary significantly (P>0.05), C. flavipes recovered significantly faster following chill-coma and had higher HKDT compared to C. sesamiae. The results suggest marked differential basal thermal tolerance responses between

2018 PLoS ONE PubMed abstract

427. Testing physiologic monitor alarm customization software to reduce alarm rates and improve nurses' experience of alarms in a medical intensive care unit. (Full text)

Testing physiologic monitor alarm customization software to reduce alarm rates and improve nurses' experience of alarms in a medical intensive care unit. Clinicians in intensive care units experience alarm fatigue related to frequent false and non-actionable alarms produced by physiologic monitors. To reduce non-actionable alarms, alarm settings may need to be customized for individual patients; however, nurses may not customize alarms because of competing demands and alarm fatigue.To examine (...) Coma Scale scores (p = 0.014), but otherwise were comparable to those pre-intervention. Nurses reported less time spent on non-actionable alarms post-intervention than pre-intervention (p = 0.026). Also lower post-intervention were the proportions of nurses who reported that alarms disturbed their workflow (p = 0.027) and who encountered a situation where an important alarm was ignored (p = 0.043). The majority (>50%) agreed that the software supported setting appropriate alarm limits and was easy

2018 PLoS ONE PubMed abstract

428. ICU Admission, Discharge, and Triage Guidelines (Full text)

a total triage score ( ). In the validation study, Barfod et al ( ) found that among the vital signs, the best predictors of hospital mortality were respiratory rate, oxygen saturation, systolic blood pressure, and Glasgow Coma Scale score. Among the complaints, dyspnea and altered mental status had the highest association with mortality (12% and 11%, respectively). Other studies have reviewed the use of abnormal vital signs for deciding ICU admissions. O’Connell et al ( ) reviewed their data after (...) ; diagnosis; systolic blood pressure; pulse; respiratory rate; PaO 2 ; concentrations of creatinine, bilirubin, bicarbonate, and albumin; vasopressor use; Glasgow Coma Scale score; Karnofsky performance status score; operative status; and chronic disorders. The training and validation samples showed excellent discrimination (area under the receiving operating characteristic curve > 0.8). However, the tool is in its early stages, the assignment of the individual score is not simple (a computerized process

2016 Society of Critical Care Medicine PubMed abstract

429. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

through an end date of December 31, 2013 (including ePub publications). While preference was given to RCTs, other forms of resource material were used to support the response, including nonrandomized cohort trials, prospective observational studies, and retrospective case series. Use of publications was limited to full-text articles available in English on adult humans. For all included RCTs, two readers completed data abstraction forms (DAFs) examining the data and assessing the quality (...) : Tolerance may be determined by physical examination, passage of flatus and stool, radiologic evaluations, and absence of patient complaints such as pain or abdominal distention. GI intolerance is usually defined by vomiting, abdominal distention, complaints of discomfort, high NG output, high GRV, diarrhea, reduced passage of flatus and stool, or abnormal abdominal radiographs. Metheny reported that more than 97% of nurses surveyed assessed intolerance solely by measuring GRVs (the most frequently cited

2016 Society of Critical Care Medicine

430. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: Official ATS/IDSA Clinical Practice Guidelines

-universal useof antibiotics early inthe course ofARDS.When VAP does occur, however, the microbial causes appear no different than those among patients without ARDS who have required me- chanical ventilation for similar periods of time and who have experienced similar levels of exposure to antibiotic therapy [36]. In contrast, coma upon ICU admission had a protective effective against MDR VAP. This effect is related to the in- creased propensity of neurotrauma patients to develop VAP early in their ICU

2016 American Thoracic Society

431. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

included RCTs, 2 readers completed data abstraction forms (DAFs) examining the data and assessing the quality of the research methodology to produce a shared evaluation achieved by consensus for each study (example of DAF provided in online supplemental material). DAFs were constructed only for RCTs. When the strongest available evidence was a published meta‐analysis, the studies from the meta‐analysis were used to determine the quality of the evidence and assessed by 2 evidence assessors. The data (...) inadequate nutrient delivery. Rationale: Tolerance may be determined by physical examination, passage of flatus and stool, radiologic evaluations, and absence of patient complaints such as pain or abdominal distention. GI intolerance is usually defined by vomiting, abdominal distention, complaints of discomfort, high NG output, high GRV, diarrhea, reduced passage of flatus and stool, or abnormal abdominal radiographs. Metheny et al reported that more than 97% of nurses surveyed assessed intolerance

2016 American Society for Parenteral and Enteral Nutrition

432. Lower Extremity Peripheral Artery Disease: Guideline on the Management of Patients With

of Guideline e76 2.CLINICAL ASSESSMENT FOR PAD ... e79 2.1. History and Physical Examination: Recommendations e79 3.DIAGNOSTIC TESTING FOR THE PATIENT WITH SUSPECTED LOWER EXTREMITY PAD (CLAUDICATION OR CLI) ... e80 3.1. Resting ABI for Diagnosing PAD: Recommendations e80 3.2. Physiological Testing: Recommendations . e81 3.3. Imaging for Anatomic Assessment: Recommendations e86 4.SCREENING FOR ATHEROSCLEROTIC DISEASE INOTHERVASCULARBEDSFORTHE PATIENT WITH PAD .. ... e87 4.1. Abdominal Aortic Aneurysm (...) ), no further imaging or intervention is warranted. JACC VOL. 69, NO. 11, 2017 Gerhard-Herman et al. MARCH 21, 2017:e71–126 2016 AHA/ACC Lower Extremity PAD Guideline e793. DIAGNOSTIC TESTING FOR THE PATIENT WITH SUSPECTED LOWER EXTREMITY PAD (CLAUDICATION OR CLI) 3.1. Resting ABI for Diagnosing PAD: Recommendations TABLE 5 History and/or Physical Examination Findings Suggestive of PAD History n Claudication n Other non–joint-related exertional lower extremity symptoms (not typical of claudication) n

2016 American College of Cardiology

434. Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

of Recommendations Assessment, Development and Evaluation HR Hazard ratio ICD-10 International Classification of Diseases, 10th Revision IR Immediate release IRR Incidence rate ratio ITT Intention to treat MDS Minimum data set MI Myocardial infarction MMSE Mini-Mental State Examination NC Not calculated NIA National Institute on Aging NIMH National Institute of Mental Health NINCDS/ADRDA National Institute of Neurologi- cal and Communicative Diseases and Stroke/Alzhei- mer’s Disease and Related Disorders (...) of symptom recurrence, which is unpredictable. There is insufficient evidence to determine whether individuals with more severe dementia, psychosis, or agitation will have a greater risk of symptom recurrence with discontinuation. There are also no data on whether symptom re- sponse is equivalent if antipsychotic medication is resumed after recurrence of symptoms. No studies have examined the use of long-acting injectable antipsychotic medications in individ- uals with dementia. However, the longer

2016 American Psychiatric Association

435. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients (Full text)

, American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography divides echocardiography skills into two competency levels: basic and advanced ( ). BCU is performed as a goal-directed examination using transthoracic echocardiography (TTE) or TEE 2D imaging to identify specific findings and to answer focused clinical questions. ICU providers may readily achieve competence in basic BCU. Competence in advanced BCU allows (...) , that the unprecedented expansion of bedside ultrasonography as a bedside tool will increase the number of clinicians utilizing this technology who might benefit from these guidelines . These guidelines are not intended to endorse a specific type of BCU—complete or focused—nor the use of specific ultrasound systems—portable versus full sized. Instead, these guidelines attempt to provide the rationale for intensivists with different levels of expertise and training to perform bedside examination or to seek expert

2016 Society of Critical Care Medicine PubMed abstract

436. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Comprehensive Medical Care of Patients with Obesity

prospective or case-controlled trials; MRI = magnetic resonance imaging; MUFA = monoun- saturated fatty acid; NAFLD = nonalcoholic fatty liver disease; NASH = nonalcoholic steatohepatitis; NES = night eating syndrome; NHANES = National Health and Nutrition Examination Surveys; NHLBI = National Heart, Lung, and Blood Institute; NHS = Nurses’ Health Study; NICE = National Institute for Health and Care Excellence; OA = osteoarthritis; OGTT = oral glucose tolerance test; OR = odds ratio; OSA = obstructive (...) ; CSS]; 4 [EL 3; SS]; 5 [EL 3; SS]). Data from the National Health and Nutrition Examination Surveys show that roughly 2 of 3 United States (U.S.) adults have overweight or obesity, and 1 of 3 adults has obesity (1 [EL 3; SS]; 2 [EL 2; MNRCT]; 3 [EL 3; CSS]). The impact of obesity on morbidity, mortal- ity, and health care costs is profound. Obesity and weight- related complications exert a huge burden on patient suf- fering and social costs (6 [EL 3; SS]; 7 [EL 3; SS]). Obesity is estimated to add

2016 American Association of Clinical Endocrinologists

438. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications (Full text)

, several risk stratification models for quantifying morbidity and mortality in IE patients overall and particularly in those undergoing valve surgeries have been developed and validated. Finally, daptomycin has been evaluated in the treatment of S aureus bacteremia and IE in a randomized, controlled trial. Several rigorously conducted observational studies , and a randomized, controlled trial have examined the impact and timing of valve surgery in IE management. In addition, updated international (...) bacteremia or fungemia, evidence of active valvulitis, peripheral emboli, and immunological vascular phenomena. In most patients, however, the “textbook” history and physical examination findings may be few or absent. Cases with limited manifestations of IE may occur early during IE, particularly among patients who are injection drug users (IDUs), in whom IE is often the result of acute S aureus infection of right-sided heart valves. Acute IE may evolve too quickly for the development of immunological

2016 Infectious Diseases Society of America PubMed abstract

439. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient

meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided. Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles (...) (in-service exam committee). Dr. Patterson disclosed family relationships with makers of healthcare products (he is an employee of the University of Nebraska Medical Center) and disclosed non-governmental research grant funding (Co-PI for a Surviving Sepsis in Resource Limited Environment Grant from European Society of Intensive Care Medicine and Hellman Foundation). Dr. Sands disclosed family relationships with makers of healthcare products, for-profit of healthcare services/products, and with providers

2016 Society of Critical Care Medicine

440. Guidelines for the Management of Severe Traumatic Brain Injury (4th edition)

in the comprehensive guideline document. These are available online at . Despite these improvements, the recommendations are limited in many areas, reflecting persisting gaps in the evidence base for severe traumatic brain injury (TBI) management. Although there have been numerous new publications in the field since the Third Edition of the Guidelines was published in 2007, many repeat the same methodologic flaws found in previous research. The comprehensive guideline document includes an examination (...) in the comprehensive guideline document, and the search strategies are in Appendix D to the same document. Both documents are available online at . The key criteria for including studies in the review were as follows: the population was adult patients with severe TBI (defined as Glasgow Coma Scale Score of 3-8), and the study assessed an included outcome (mortality; neurologic function; or appropriate, selected, intermediate outcomes for the topic). Differences were resolved via consensus or by a third reviewer

2016 Congress of Neurological Surgeons

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